Opthalmic microsurgical instrument

ABSTRACT

In some embodiments, a microsurgical instrument includes a trocar having a rigid, hollow shaft formed with a lumen extending from a proximal end to a distal end of the shaft. The distal end of the shaft may be shaped for tissue penetration. The instrument may further include a composite microcannula slidably engaged with the trocar in the lumen. The microcannula includes a light guide and a flexible hollow tube having an outer diameter less than an inner diameter of the lumen in the trocar. Other embodiments include placing the microcannula in the lumen of the trocar, illuminating the end of the trocar by illuminating the end of the microcannula, advancing the trocar from a selected entry point on an eye into a selected structure in the eye, and extending the illuminated end of the microcannula from the trocar into the selected structure.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of copending application Ser.No. 15/892,833 filed Feb. 9, 2018, incorporated herein by reference inits entirety, which claims the benefit of U.S. Provisional PatentApplication No. 62/574,136, filed Oct. 18, 2017, incorporated herein byreference in its entirety.

FIELD OF THE INVENTION

Embodiments are related to surgical apparatus for treatment of eyediseases such as glaucoma.

BACKGROUND

Aqueous humor is a transparent, watery fluid produced within an eye,filling the anterior and posterior chambers of the eye, transportingagents needed by eye tissues and helping to maintain the eye's roundedshape by fluid pressure. Aqueous humor flows out of the eye through afluid drainage network including the trabecular meshwork and Schlemm'scanal, a porous, circumferential fluid passage coupled to collectorchannels and veins. Blockage or collapse of parts of the eye's drainagenetwork can lead to an increase in intraocular pressure, a conditionthat may be associated with degraded vision and eye diseases such asglaucoma.

Surgical treatment may be used to reduce intraocular pressure byimproving the flow of aqueous humor. Some surgical treatments involvemaking relatively large incisions through the sclera, the tough whiteouter covering of the eye, forming a flap of tissue folded back toexpose the trabecular meshwork or other parts of the flow path foraqueous humor. Exposed parts of the drainage network may then bemodified by removing tissue or forming new drainage channels. Anincision through the sclera may lead to a loss of fluid pressure insidethe eye and a collapse of one or more of the chambers. It may benecessary to support the eye's natural shape by injecting a viscoelasticfluid into one of the chambers. A viscoelastic fluid has a viscositythat changes from dynamic to static flow conditions, flowing withrelatively low viscosity when subjected to shear stress and assuming agel-like, high-viscosity state under static conditions.

Surgical treatments involving incisions into the eye may increase therisk of post-surgical complications such as infection and the formationof scar tissue. Other treatment procedures less disruptive to the eyehave been developed. For example, the flow of aqueous humor may beimproved by passing a microcannula through parts of the eye's drainagenetwork to remove obstructions or re-open collapsed fluid passages.Additionally, it can be advantageous to deliver drugs or drug-elutingdevices or materials into tissue structures. Notably, the delivery ofdrugs and drug-eluting devices to Schlemm's Canal can be beneficial dueto Schlemm's canal being outside the immune privileged area that isfound inside the main body of the human eye. The microcannula mayinclude a flexible hollow tube having an outer diameter small enough topermit the microcannula to be introduced into Schlemm's canal or someother part of the eye's drainage network. The microcannula may besufficiently flexible to follow the curve of Schlemm's canal or anotherpart of the drainage network while the microcannula is pushed fromoutside the eye, for example through a surgically-formed flap aspreviously described or through a puncture of the sclera. Themicrocannula may be used to mechanically expand a selected part of thedrainage channel in the eye, or may be used to inject materials,objects, fluids, drugs, or viscoelastic to apply fluid pressure forimproving flow through part of the eye's drainage system. Or, amicrosurgical cutting, penetrating, or grasping instrument may be passedthrough the microcannula to guide the instrument to a part of the eye tobe surgically modified.

Some microsurgical instruments have a microcannula slidably engaged witha hollow, flexible outer sheath. The flexible outer sheath may be usedto position an entry point for the microcannula into the interior of aneye, with the microcannula passing through a lumen in the flexible outersheath and the outer sheath held stationary with respect to the eye. Anend of the microcannula may be extended from an end of the sheath toenter a selected part of an eye. However, the flexibility of the outersheath may make it difficult for the sheath to penetrate the sclera orother tissue to enable the microcannula to enter drainage structures orother treatment areas inside the eye. It may be necessary to make anincision or puncture with a separate instrument to permit the flexiblesheath to be positioned accurately for placement and guidance of themicrocannula. Or, the microcannula may be provided with a tip shaped fortissue penetration, possibly limiting the use of the microcannula fordelivering a payload into the interior of an eye.

SUMMARY

An example apparatus embodiment includes a trocar and a compositemicrocannula. An example of a trocar includes a rigid shaft having aproximal end and a distal end. The rigid shaft may be formed with alumen extending from the proximal end to the distal end. The distal endof the rigid shaft on the trocar may be shaped for tissue penetration.

A composite microcannula may be positioned in the lumen of the trocar.An example of the composite microcannula may include a flexible hollowtube having an outer diameter less than an inner diameter of the lumenin the trocar. The example of a composite microcannula may furtherinclude a light guide.

Another example apparatus embodiment includes a trocar for ophthalmicsurgery. The example of a trocar includes a rigid hollow shaft having adistal end shaped for tissue penetration. The hollow shaft is formedwith a lumen extending from a distal end of the hollow shaft to aproximal end of the hollow shaft. The example of a trocar furtherincludes a transition structure attached to the proximal end of thehollow shaft. The transition structure may be formed with an aperturefor admitting a composite microcannula into the lumen. The example of atrocar may further include a light source disposed to illuminate thedistal end of the rigid hollow shaft. A distal edge of the lumen in thehollow shaft may be smoothed to reduce abrasion and/or cutting of asolid object passing through the lumen and out of the trocar. Theexample of a trocar may further include a finger grip extending outwardfrom the transition structure.

An example method embodiment includes placing a distal end of acomposite microcannula within a lumen of a trocar; illuminating thedistal end of the composite microcannula, thereby illuminating thedistal end of the trocar; selecting a trocar entry point on an eye andpositioning the trocar at the selected entry point; advancing the trocarat the selected entry point until the illuminated distal end of thetrocar is observed to enter a selected structure in the eye; andextending the composite microcannula from the distal end of the trocartoward a target region in the eye, thereby transitioning fromilluminating the distal end of the trocar to illuminating tissue outsidethe trocar.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a pictorial view of an example embodiment of a microsurgicalinstrument including a trocar with a rigid hollow shaft and a flexiblecomposite microcannula.

FIG. 2 is a top view of an example of a trocar in accord with anembodiment.

FIG. 3 is a side view of the example of a trocar of FIG. 2 .

FIG. 4 is a cross-sectional view A-A of the example of a trocar of FIGS.1-3 . A section line labelled A-A in FIG. 3 shows the position andviewing direction for the cross-sectional view in FIG. 4 .

FIG. 5 is an enlarged partial cross-sectional view B of the rigid hollowshaft of FIGS. 1-4 , showing an example of a distal end shaped fortissue penetration and further showing an example of a smoothed distaledge of the lumen in the trocar. The position of View B in FIG. 5 ismarked with a broken line in FIG. 4 .

FIG. 6 is a partial top view of an example of a composite microcannulain accord with the embodiments of the microsurgical instrument.

FIG. 7 is a cross-sectional view C-C of the example compositemicrocannula of FIG. 6 . The position and viewing direction forcross-sectional view C-C in FIG. 7 is marked with a longitudinal sectionline C-C in FIG. 6 .

FIG. 8 is a cross-sectional view D-D of the example compositemicrocannula of FIG. 6 . The position and viewing direction forcross-sectional view D-D in FIG. 8 is marked with a transverse sectionline D-D in FIG. 6 .

FIG. 9 is an alternative cross-sectional view D-D of another example ofa composite microcannula in accord with embodiments of the microsurgicalinstrument. The position and viewing direction for alternativecross-sectional view D-D in FIG. 9 is marked with the transverse sectionline D-D in FIG. 6 .

FIG. 10 is an alternative cross-sectional view D-D of another example ofa composite microcannula in accord with embodiments of the microsurgicalinstrument. The position and viewing direction for alternativecross-sectional view D-D in FIG. 10 is marked with the transversesection line D-D in FIG. 6 .

FIG. 11 is an alternative cross-sectional view D-D of another example ofa composite microcannula in accord with embodiments of the microsurgicalinstrument. The position and viewing direction for alternativecross-sectional view D-D in FIG. 11 is marked with the transversesection line D-D in FIG. 6 .

FIG. 12 is an alternative cross-sectional view A-A of another example ofa trocar, further illustrating an example of a composite microcannulaoffset in a proximal direction from the distal end of the trocar, andfurther illustrating an example of an illuminated distal end of thetrocar.

FIG. 13 continues the example of FIG. 12 , showing an example of theilluminated distal end of the composite microcannula extending outwardfrom the distal end of the lumen in the trocar.

FIG. 14 is an alternative cross-sectional view D-D showing anotherexample of a composite microcannula with two light guides in theinterior longitudinal void of the composite microcannula's flexiblehollow tube.

FIG. 15 is an alternative cross-sectional view D-D showing anotherexample of a composite microcannula with two light guides, one lightguide in the interior of the composite microcannula's flexible hollowtube, and another light guide contacting an external surface of theflexible hollow tube.

FIG. 16 is an alternative cross-sectional view D-D showing anotherexample of a composite microcannula with two light guides, one lightguide in the interior of the composite microcannula's flexible hollowtube, and another light guide between the hollow tube and an outersleeve.

FIG. 17 is an alternative cross-sectional view D-D showing anotherexample of a composite microcannula with two light guides, one lightguide in the interior of the composite microcannula's flexible hollowtube, and a second light guide held against the flexible hollow tube byan outer coating applied over the second light guide and the flexiblehollow tube.

FIG. 18 is a block diagram of an alternative apparatus embodimentincluding a positioner for displacing the composite microcannularelative to the trocar, and optionally including a fluid injector forintroducing fluid into the composite microcannula.

FIG. 19 shows a top view of an example of a microsurgical instrumentembodiment with a positioner and a trocar.

FIG. 20 is a cross-sectional view E-E of the example of a positionerfrom FIG. 19 . A location and viewing direction for cross-sectional viewE-E in FIG. 20 is marked with a longitudinal section line labeled E-E inFIG. 19 .

FIG. 21 shows a pictorial view of an example microsurgical instrumentembodiment including a positioner with the distal tip of the trocarpassing through the sclera of an eye into Schlemm's canal, illustratingan example of light emitted from the illuminated distal end of thetrocar to accurately indicate the position of the trocar.

FIG. 22 shows a pictorial view with the example microsurgical instrumentand trocar in the same position relative to Schlemm's canal as in FIG.21 , and further illustrating an example of the illuminated distal tipof the composite microcannula extended outward from the trocar along thecircumferential path of Schlemm's canal.

FIG. 23 is another alternative cross-sectional view A-A of the exampleof a trocar of FIG. 1 , showing an example of a composite microcannulawith its light guide passing through the lumen of the trocar, andfurther showing positioned in the lumen a second, optional light guideseparate from the light guide in the composite microcannula.

FIG. 24 shows a partial pictorial view of the example of a trocar with acomposite microcannula and a second light guide as in the example ofFIG. 23 , illustrating an example of the illuminated distal ends of thetrocar and composite microcannula separated from one another along thecircumferential path of Schlemm's canal.

FIG. 25 shows an alternative cross-sectional view D-D of an example of acomposite microcannula embodiment carrying an example of an optionalfluid payload and an example of an optional solid payload inside theflexible hollow tube.

FIG. 26 shows a pictorial view of an example of a trocar entry pointmarking instrument.

FIG. 27 shows a view toward examples of marking surfaces on marking padson the trocar entry point marking instrument of FIG. 26 .

FIG. 28 shows a side view of the example trocar entry point markinginstrument of FIGS. 26-27 .

FIG. 29 shows a view toward an example of the sclera and iris of a humaneye, illustrating an example of a pattern of tangent lines formed by thetrocar entry point marking instrument of FIGS. 26-28 .

FIG. 30 illustrates an example of some steps included in a method forinserting a trocar through the sclera of an eye and advancing acomposite microcannula from the trocar into a structure such asSchlemm's canal.

FIG. 31 is a partial top view of another example of a compositemicrocannula in accord with the embodiments of the microsurgicalinstrument.

FIG. 32 is a cross-sectional view F-F of the example compositemicrocannula of FIG. 31 . The position and viewing direction forcross-sectional view F-F in FIG. 32 is marked with a longitudinalsection line F-F in FIG. 31 .

FIG. 33 is a cross-sectional view G-G of the example compositemicrocannula of FIGS. 30-31 . The position and viewing direction forcross-sectional view G-G in FIG. 33 is marked with a transverse sectionline G-G in FIG. 31 .

FIG. 34 is a view toward a top side of another an example of amicrosurgical instrument embodiment with a positioner and a trocar.

FIG. 35 is a side view of two of the microsurgical instrument examplesof FIG. 34 , with the upper device showing the composite microcannula inan example of a retracted position and the lower device showing thecomposite microcannula in an example of an extended position.

FIG. 36 continues the example of FIGS. 34-35 , showing the examples of amicrosurgical instrument in cross-sectional view H-H for the retractedposition of the composite microcannula and cross-sectional view K-K forthe extended position of the composite microcannula. The positions ofcross sections H-H and K-K are marked by section lines H-H and K-K inFIG. 35 .

DESCRIPTION

Example embodiments in accord with the invention are described herein. Atrocar having a rigid hollow shaft with a distal end shaped for tissuepenetration is configured to pierce biological tissue, for example thesclera of an eye, forming a very small entry point into the tissue for acomposite microcannula passing through a lumen of the trocar. Thecomposite microcannula, which may also be referred to herein as acomposite microcatheter, includes a light guide for illuminating thedistal end of the microcannula. A light source may be coupled to thecomposite microcannula and/or trocar to illuminate the distal end of therigid hollow shaft by directing light through the light guide into thelumen of the trocar, thereby enabling an accurate determination of theposition of the distal end of the trocar, a visual indication of theentry of the trocar a structure in the eye, and a visual indication ofthe position of the distal end of the composite microcannula as itadvances toward a target region for treatment. The illuminated distalend of the composite microcannula may be used to determine when themicrocannula has deviated from a preferred path, for example leaving apreferred path through Schlemm's canal and entering another channel orchamber such as a collector channel or another part of the eye'sdrainage system.

Embodiments are effective for providing a visual indication of thelocation of the distal end of the trocar by observing light emitted fromthe trocar through tissue which may include the sclera, trabecularmeshwork or other tissue, including tissue not associated with an eye.Light passing through the sclera or other tissue from the trocar furtherindicates a direction of travel of the trocar. The position anddirection of travel of the composite microcannula may also be accuratelydetermined by visual observation of the light emitted from the tip ofthe microcannula. An embodiment may be accurately guided into tissuesand/or tissue spaces such as, but not limited to, the trabecularmeshwork, Schlemm's canal, and collector channels. Conversely, anembodiment may be accurately guided to specifically avoid entering aselected tissue or tissue space. The tissues in the eye and the positionand direction of travel of an embodiment may be observed directly, witha camera, with a gonioprism, with other optical aids, or any combinationof these devices and methods.

In some embodiments, a second light guide enables independent, andoptionally simultaneous, illumination of the distal ends of the trocarand the composite microcannula. In other embodiments, a payloadcomprising a fluid and/or a solid object may be delivered through thecomposite microcannula to a target region in an eye. Examples of a fluidpayload include, but are not limited to, drugs including gene therapy,stem cell, and other fluid-based drugs, a viscoelastic fluid, water, anda saline solution. Examples of a solid payload include, but are notlimited to, devices, particles, nano particles, small devices includingdrug-eluting examples of solid payloads, a microsurgery instrument suchas forceps, an instrument for penetrating and/or cutting tissue, astent, a light guide, and a wire. As used herein, a light guide refersto an optical element capable of transmitting electromagnetic energyreceived at an input surface to an output surface through an interveningoptical medium. Examples of a light guide include, but are not limitedto, one or more mirrors arranged to direct a light beam from a source toa destination, a flexible optical fiber, a bundle of optical fibers, anda rigid light pipe.

Some embodiments include a positioner for displacing the compositemicrocannula relative to the distal end of the trocar. A positioner mayoptionally include a microcannula displacement mechanism configured toextend and optionally retract the composite microcannula. The positionermay further optionally include a fluid injector configured to move fluidfrom a fluid reservoir into the composite microcannula and possibly intoa selected target region in an eye. Some embodiments of a positionerinclude a light source disposed to emit light into the light guide ofthe composite microcannula and optionally into a second light guidecoupled to the trocar, when a second light guide is provided. Apositioner may enable accurate advancement and/or retraction of thecomposite microcannula without disturbing the microcannula's entry pointinto the eye, possibly reducing an amount of time needed to complete atreatment procedure and reducing a risk of damage to eye tissue.

Embodiments of an ophthalmic microsurgical instrument may be configuredto smoothly and continuously transition from illuminating the distal endof the trocar to illuminating tissue outside the trocar, therebyenabling very precise determination of the position of the trocar andcomposite microcannula relative to structures in the eye. The very smallpuncture made by the trocar in the sclera or other parts of the eyecontrasts with the relatively large incisions required by previoussurgical techniques that raise a flap of tissue from the sclera toaccess structures in the interior of the eye. The small puncture reducespatient discomfort and risk of post-operative complications such asscarring and infection. Preparing, monitoring and closing the surgicalarea are faster and less complicated than methods using incisionsthrough the sclera, possibly enabling embodiments to be employed withless stringent levels of sterility and patient monitoring than may bepracticed in an operating room for surgical procedures, and possiblypermitting more rapid patient recovery and healing from surgicalprocedures.

An example embodiment of a microsurgical instrument appears in FIG. 1 .The example embodiment 100 includes a trocar 200 configured to receive acomposite microcannula 300. The composite microcannula 300 may beslidably engaged with the trocar 200, passing through a trocar connector222 at the proximal end 204 of the trocar, a transition structure 214,and a lumen 208 formed in a rigid hollow shaft 206 extending outwardfrom the transition structure 214 to the distal end 202 of the trocar200. The rigid hollow shaft 206 is preferably formed with a distal end210 shaped for tissue penetration. One or more of an optional fingergrip 216 may be attached to, or alternately formed as an integral partof, the trocar connector 222 and/or the transition structure 214.

In the example of FIG. 1 , the composite microcannula 300 is shown withseveral bends and curves to illustrate the flexibility of the hollowtube 302 forming much of the length of the composite microcannula. Theflexibility of the composite microcannula enables the microcannula tofollow the curved walls of a structure in the eye, for example Schlemm'scanal, without puncturing or damaging the walls of the structure. Anembodiment of the composite microcannula 300 may be formed with segmentsof the microcannula having flexural rigidity in a range from 3.0×10⁻¹¹kN−m² to 2.9×10⁻¹⁰ kN−m². Parts of the composite microcannula near thedistal and/or proximal ends may optionally be more rigid than otherparts of the composite microcannula. The rigid hollow shaft 206 of thetrocar 200 is substantially stiffer than the composite microcannula andis preferably formed with a flexural rigidity of at least 1.5×10⁻⁸kN−m², stiff enough to readily penetrate the sclera and other tissue inan eye. A trocar with flexural rigidity greater than the preferredminimum value may eliminate the need for a separate surgical instrumentto form a puncture through an outer surface of an eye.

The composite microcannula 300 may include an optional microcannulaconnector 314 at the proximal end 310 of the flexible hollow tube 302.The microcannula connector may include connections for introducing apayload into the composite microcannula and for coupling light from alight source into the composite microcannula. A liquid, solid, orgaseous payload introduced into the proximal end 310 may be transportedthrough the hollow tube 302 to the distal end 308 of the compositemicrocannula for delivery to a target region in an eye. Light incidenton the proximal end 310 may travel to the distal end 308 to create anilluminated distal end 326 of the composite microcannula. An optionallight diffuser 311 may be provided at the distal end 308 to disperselight in many directions, thereby indicating the precise location of thedistal end of the composite microcannula as it moves through channelsand chambers in an eye. Light may travel from the proximal end to thedistal end of the composite microcannula by internal reflection from thewalls of the flexible hollow tube 302, through a liquid introduced intothe hollow tube 302, or through one or more light guides included withsome embodiments of a composite microcannula.

An example embodiment of a trocar 200 is shown in a top view in FIG. 2and a side view in FIG. 3 . In the example of FIG. 3 , the optionalfinger grips 216 visible in FIG. 2 have been omitted. The trocarconnector 222 at the proximal end 204 of the trocar 200 may be a luerconnector, for example a slip-fit or twist-lock luer connector. Otherconnectors capable of forming a leak-resistant seal may alternatively beused. The rigid hollow shaft 206 of the trocar 200 attaches to thetransition structure 214. A lumen 208 in the rigid hollow shaft 206 isin fluid communication with void spaces in the transition structure andtrocar connector, thereby enabling fluid to be introduced into the lumen208. The lumen 208 of the trocar 200 extends through the distal endshaped for tissue penetration 210.

Cross-sectional view A-A in FIG. 4 and partial enlarged view B in FIG. 5illustrate some internal details of an example of a trocar 200 in accordwith an embodiment. The rigid hollow shaft 206 is held firmly by thetransition structure 214 attached to the trocar connector 222. The lumen208 through the rigid hollow shaft 206 is in fluid communication withvoid spaces 224 in the trocar connector 222. The void space 224 may beformed with a conical microcannula guide surface 221 near the proximalend of the hollow shaft 206. The conical surface 221 may deflect acomposite microcannula toward the lumen 208 through an aperture 223formed in the transition structure 214 near the distal end of the voidspace 224.

The distal edge 212 of the lumen 208 is preferably smoothed, for exampleby rounding the edge 212 all the way around the distal end of the lumen.The smoothed distal edge 212 reduces abrasion or cutting of materialfrom the composite microcannula when the microcannula slides across thedistal edge of the trocar lumen. If left unsmoothed, the distal edge ofthe trocar lumen may be sharp enough to remove material from thecomposite microcannula. Reducing an amount of material cut or abradedfrom the composite microcannula reduces undesirable deposition of suchmaterial in an eye.

View B in FIG. 5 further illustrates an example of an outer diameter 219of the rigid hollow shaft 206 and an inner diameter 218 of the lumen 208through the rigid hollow shaft 206. The outer diameter 219 may be in arange from about 200 microns to about 700 microns. For example, sometrocar embodiments have a rigid hollow shaft with an outer diameter 219of 450 microns. Other trocar embodiments have a rigid hollow shaft withan outer diameter 219 of 250 microns. The inner diameter 218 ispreferably larger than a largest transverse dimension 306 of a compositemicrocannula configured to pass slidably through the lumen, for examplean outer diameter 306 of the flexible hollow tube 302, a largesttransverse dimension 306 across the tube 302 and an outer coating 321applied to the tube, a largest transverse 306 dimension across thehollow tube 302 and an external light guide 304 in contact with thetube, or an outer diameter 306 of a sleeve 320 surrounding the tube 302.

An example embodiment of a composite microcannula 300 is shown in a topview in FIG. 6 , a longitudinal cross-sectional view C-C in FIG. 7 , andalternative transverse cross-sectional views D-D in FIGS. 8-11 . Assuggested in FIGS. 6, 7, and 8 , light guide 304 may be positioned in alongitudinal void 303 extending from the proximal end 310 to the distalend 308 of the flexible hollow tube 302. The longitudinal void 303inside the composite microcannula 300 may also be referred to as thelumen 303 of the composite microcannula. The void 303 may serve as afluid path 324 for a fluid introduced into the flexible hollow tube 302.A payload introduced onto the composite microcannula may follow thefluid path 324 as the payload moves from the proximal end 310 to thedistal end 308.

The light guide 304 may be formed separately from the flexible hollowtube as suggested in the previous examples. Alternatively, a light guidemay be formed as an internal layer of the flexible hollow tube 302 asshown in the examples of FIGS. 31, 32, and 33 . The light guide 304 maybe disposed as a concentric layer of material adjacent the void 303 inthe composite microcatheter 300. An index of refraction of the materialof the light guide 304 preferably differs sufficiently from an index ofrefraction of the material of the flexible hollow tube 302 to enableefficient coupling of light from a light source to the distal end 308 byinternal reflection through the light guide. The layer of materialforming the light guide 304 may be formed by molding, chemicaldeposition, or by mechanically inserting a hollow tube into the flexiblehollow tube 302. Although the figures show an example of a light guidemade from a single layer of material, the light guide may alternativelybe made of several layers of material, each with a selected value ofrefractive index, or may alternatively be made with a refractive indexthat varies with distance from an edge of the light guide.

FIGS. 31, 32, and 33 further illustrate an example of a light diffuser311 having a reduced outside diameter 312 compared to the outsidediameter of the light diffuser 311 in the examples of FIGS. 6 and 7 .The light diffuser 311 may alternatively be formed as a rounded end ofthe flexible hollow tube 302, where the diffuser has a radius equal tohalf the diameter 313 of the flexible hollow tube.

A second light guide and/or other liquid or solid payloads may be passedthrough the void 303 surrounded by the light guide 304. In someembodiments, the light guide 304 entirely surrounds the void space 303in the flexible hollow tube 302. Alternatively, the light guide may benot entirely surround the void space, for example being formed as ahollow tube split longitudinally in half, in quarter, or some otherfraction of a complete hollow tube.

An outer diameter 306 of the composite microcannula 300 may be thelargest diameter found on the composite microcannula, for example thediameter 312 in FIG. 6 . The outer diameter 306, for example the largerof the outside diameter 312 of an optional light diffuser 311 at thedistal end 308 and the outside diameter 313 of the hollow tube 302, ispreferably less than the internal diameter 218 of the lumen 208 in thetrocar 200.

The distal end 308 of the composite microcannula corresponds to theilluminated end 326 when light incident on the proximal end 310 of thelight guide 304 is emitted from the distal end 308. As suggested inFIGS. 6 and 7 , the distal end 308 of the composite microcannula may berounded to reduce tissue trauma and to disperse light from the lightdiffuser 311 in many directions to enhance the visibility of theilluminated distal end 326. The outside diameter 312 of the lightdiffuser may be larger than the outside diameter 313 of the hollow tube302. Alternately, the diameters (312, 313) may be approximately equal toone another.

For some embodiments, a length of a flexible segment 322 of thecomposite microcannula 300 may be a few millimeters longer than acircumferential length of Schlemm's canal. The circumferential length ofSchlemm's canal in a human eye is about 36 millimeters. For someembodiments of a composite microcannula 300, the length of the flexiblesegment 322 may be greater than 40 millimeters (1.6 inches). A length ofthe flexible segment 322 may optionally be substantially longer than thecircumferential length of Schlemm's canal, for example to permit thecomposite microcannula to connect to a light source or fluid injectionapparatus or to provide a convenient length outside the proximal end ofthe trocar for gripping the composite microcannula with forceps orfingers.

Alternatively, the length of the flexible segment 322 of the compositemicrocannula 300 may be about 20 millimeters, allowing catheterizationof Schlemm's canal in two passes. A first pass may proceed through abouthalf of the length of Schlemm's canal in a clockwise direction. A secondpass may proceed through the other half of Schlemm's canal in acounterclockwise direction.

In the example of a composite microcannula 300 in FIG. 8 , the lightguide 304 is positioned within the longitudinal void 303. The lightguide has a smaller diameter than the inner diameter 307 of the flexiblehollow tube 302. The outer diameter 306 of the composite microcannula300 may be the outer diameter of the hollow tube 302.

In the example of a composite microcannula 300 in FIG. 9 , the lightguide 304 is positioned on the outside surface of the flexible tube 302,leaving the space inside the flexible tube 302 available fortransporting a payload through the composite microcannula. In theexample of FIG. 9 , the outer diameter 306 of the composite microcannulaincludes the dimensions of the flexible tube 302 and the light guide304.

FIGS. 10 and 11 show more examples of a composite microcannula 300 inaccord with a microsurgical instrument embodiment 100. The examplecomposite microcannula 300 in FIG. 10 positions the light guide 304outside the void 303 in the flexible hollow tube 302. An outer sleeve320 surrounds the light guide 304 and the flexible tube 302. The outerdiameter 306 of the composite microcannula may correspond to the outerdiameter of the sleeve 320 in FIG. 10 . In FIG. 11 , an example of acoating 321 has been applied over the light guide 304 and flexiblehollow tube 302. The outer diameter 306 along the flexible segment ofthe composite microcannula includes the dimensions of the hollow tube302, light guide 304, and outer coating 321. The example embodiments inFIGS. 10 and 11 both offer the full internal diameter 307 of the hollowtube 302 for carrying a payload through the longitudinal void 303.

The composite microcannula may be positioned inside the lumen of thetrocar to illuminate the distal end of the trocar while the trocar isbeing inserted into an eye. FIGS. 12 and 13 show an example of analternative configuration for a transition structure 214 and examples ofpositions of the composite microcannula. In FIG. 12 , the compositemicrocannula is positioned for lighting the distal end 202 of thetrocar's rigid hollow shaft 206. The distal end 308 of the compositemicrocannula, which in the examples of FIGS. 12-13 is also theilluminated end 326 of the microcannula, may be installed in the lumenof the trocar a preferred offset distance 626 from the distal end 202 ofthe trocar. Internal reflection in the trocar lumen causes light 614emitted from the distal end of the composite microcannula to emerge fromthe distal end of the trocar as light 612 dispersed across a wide rangeof angles, making the trocar tip visible from many different viewingdirections. The illuminated distal end 220 of the trocar may be used toidentify the precise location of the tip of the trocar inside eyetissue. For example, a readily perceived change in the brightness, asmay be observed through the trabecular meshwork gonioscopically, of theemitted light 612 indicates when the distal end of the trocar has passedthrough the sclera and entered Schlemm's canal.

Advancing the illuminated distal end 326 of the composite microcannulaout of the lumen in the trocar causes a smooth transition fromilluminating the tip of the trocar to illuminating tissue outside thetrocar. In the example of FIG. 13 , light 614 emitted from theilluminated distal end 326 of the composite microcannula may bedispersed across a wide range of angles, accurately indicating theposition of the tip of the composite microcannula inside an eye.

Some alternative embodiments of a composite microcannula include twolight guides as shown in the examples of FIGS. 14-17 . In the example ofa composite microcannula 300 in FIG. 14 , a first light guide 304 and asecond light guide 412 are disposed within the lumen 303 of the hollowtube 302. In the example of FIG. 15 , the first light guide 304 may beoutside the lumen 303 of the hollow tube 302, and the second light 412may be inside. In the example of FIG. 16 , both light guides may bepositioned as in FIG. 15 , with an outer sleeve 320 surrounding theflexible hollow tube 302 and the first light guide 304. In the exampleof FIG. 17 , both light guides may again be positioned as in FIG. 15 ,but an outer coating 321 is applied over the first light guide 304 andflexible hollow tube 302.

Some embodiments of a microsurgical instrument include a positioner fordisplacing the composite microcannula relative to the trocar. A blockdiagram of an alternative embodiment of a microsurgical instrument 100with a positioner is shown in the example of FIG. 18 . The positioner400 may include a handpiece 420 holding a microcannula displacementmechanism 425 configured to extend, and optionally retract, thecomposite microcannula 300 from the trocar 200. The trocar 200 may beattached to a trocar receiver 422, for example a receiver for the luerfitting on the trocar. The composite microcannula may pass through ahollow sleeve 433 disposed between the trocar receiver 422 and themicrocannula displacement mechanism 425. The hollow sleeve 433 mayimprove smooth extension and retraction of the composite microcannula byreducing buckling or kinking of the flexible part of the compositemicrocannula inside the positioner 400 when the microcannuladisplacement mechanism is operated. An actuator 424 mechanically linkedto the microcannula displacement mechanism 425 enables manual control ofthe length of the composite microcannula extended from the distal end ofthe trocar.

An optional light source 328 may be provided inside the positioner 400.Light output from the light source 328 may be coupled into themicrocannula connector 314 attached to the composite microcannula 300.The microcannula connector 314 may optionally be configured to receivelight from an external light source 330. In some embodiments, the lightsource 328 may be disposed to transmit light through the second lightguide 412 into the lumen of the trocar 200, possibly through theintervening trocar receiver 422.

The microcannula connector 314 may optionally provide a fluid connectionto a fluid injector 446 disposed to transfer fluid from a fluidreservoir 442 inside the handpiece 420 to the composite microcannula300. The microcannula connector 314 may alternatively be connected to anexternal fluid injector 448 configured to move fluid from an externalfluid reservoir 444 into the composite microcannula 300.

FIGS. 19 and 20 show some details of an example of a microsurgicalinstrument embodiment 100 including a positioner 400. The trocarconnector 222 at the proximal end of the trocar 200 connects to thetrocar receiver 422 at the distal end 418 of the positioner 400. Thetrocar receiver 422 may be formed as an integral part of the handpiece420, or may alternately be formed separately and strongly attached tothe handpiece. An actuator 424 slidably engages with the handpiece 420along an actuator aperture 428 to extend the composite microcannula fromthe trocar. The actuator may be attached to, or alternately formed as anintegral part of, a guide block 426 configured to track along a guideridge 430 inside the handpiece 420.

A hollow sleeve 433 may be connected at its proximal end to the guideblock 426 and at its distal end to the trocar 200. A compositemicrocannula (not visible in FIGS. 19-20 ) may be positioned inside thehollow sleeve 433. The hollow sleeve may include a fixed segment 436attached to, or alternately formed as an integral part of, the trocar200, and a movable segment 434 connected to the actuator block 426,where the length 438 of the hollow sleeve 433 includes both the fixedand movable segments. The fixed and movable segments of the hollowsleeve 433 may alternately be implemented as a hollow, collapsible andextendable bellows sleeve with concertinaed sides. The length 438 of thehollow sleeve 433 may change with a displacement of the compositemicrocannula 300 relative to the trocar 200.

An end cap 440 may close off the proximal end 416 of the positioner 400.The end cap 440 may be formed with a cap aperture 482 to permit thecomposite microcannula to extend out from the proximal end 416.

FIGS. 21 and 22 illustrate an example of a location of a trocar entrypoint on an eye and extension of the composite microcannula to followthe circumferential path of Schlemm's canal. FIGS. 21 and 22 both show apictorial view of the positioner 400 in a same position and orientationrelative to an eye 1000. Other parts of the approximately spherical eye1000 shown in simplified form in the figures include the sclera 1002,the iris 1006, the pupil 1016, and the circumferential path of Schlemm'scanal 1010 near the limbus of the eye. Schlemm's canal 1010 includes aporous, approximately circular drainage channel receiving aqueous humorflowing through the trabecular meshwork near the outer edge of the iris.Schlemm's canal is marked in the figures with a hidden line to representthe canal's approximate position behind the exterior surface of thesclera 1002. The cornea, extending outward toward the viewer above theiris 1006, may be considered to be present in FIGS. 21 and 22 , but istransparent and is not marked. A center 1018 of the pupil 1016 alsoindicates the approximate center of the iris 1006.

In the example of FIGS. 21 and 22 , the distal end 202 of the trocar 200has been inserted into the sclera 1002 at a preferred trocar entry point606, puncturing the sclera with a small hole having a diameter about thesame as the outer diameter of the rigid hollow shaft 206. The trocar maybe advanced in a direction 610 along a line 604 tangent to Schlemm'scanal 1010. In the example of FIG. 21 , the distal end 202 of the trocar200 is positioned as having just entered the interior of Schlemm's canal1010. The position of the distal end of the trocar is made visible bylight 612 radiating from the lumen of the trocar. In some embodiments100, the light 612 will have been emitted from the distal end of a lightguide with the end of the light guide offset a selected distance 626from the distal end of the trocar lumen 208 (ref. FIG. 12 ). Light 612radiating from the interior of Schlemm's canal through the sclera mayhave the visual appearance from outside the eye of a bright spot on theexterior of the eye, and this light radiating from the interior ofSchlemm's Canal through the Trabecular Meshwork may have the visualappearance of a well-defined bright spot visible across the anteriorchamber of the eye. The bright spot is a visual indication of theprecise position of the distal end 202 of the trocar 200. Light 612emitted from the end of the trocar and light 614 emitted from the end ofthe composite microcannula are represented by short wavy lines in thefigures. A gonioprism may be used to view the bright spots marking thepositions of the trocar and composite microcannula.

An example of a preferred entry point 606 of the trocar 200 through thesclera is shown in FIG. 21 along a line 604 tangent to Schlemm's canal.The entry point 606 of the trocar 200 into the sclera 1002 may be offseta predetermined distance from the limbus on the tangent line 604. Theoffset distance may be selected to cause the trocar to pass into theinterior of Schlemm's canal when inserted at the preferred entry point606 with the shaft 206 of the trocar parallel to the tangent line. Atrocar entry point marking instrument may be used to mark the surface ofan eye with the preferred entry point 606 and direction of advance forthe trocar along a tangent line 604, as will be explained in more detailwith regard to FIGS. 26-29 .

The actuator 424 on the example of a positioner 400 is shown near theproximal end of the actuator's range of travel in FIG. 21 . As theactuator is moved from its position in FIG. 21 in a distal direction tothe position shown in FIG. 22 , the microcannula displacement mechanism425, which may include the examples of the actuator block 426 and thehollow sleeve 433 from the positioner embodiment 400 of FIG. 20 , causesthe composite microcannula to extend outward from the distal end of thetrocar. The example of a displacement distance 630 in FIG. 22corresponds to a length of the portion of the composite microcannulaextending outward from the distal end of the trocar by movement of theactuator 424.

In the example of FIG. 22 , the segment of the composite microcannulaextending outward from the distal end 202 of the trocar 200 follows thecircumferential path of Schlemm's canal 1010 in a counterclockwisedirection 611 from the trocar entry point 606. Light 614 emitted fromthe distal end of the composite microcannula 300 may be visible throughthe sclera as a small spot of light, accurately indicating the positionof the distal end of the composite microcannula. The compositemicrocannula could alternately be made to follow Schlemm's canal in acounterclockwise direction by reorienting the positioner 400. Should thecomposite microcannula deviate from a preferred path, for exampleleaving Schlemm's canal and entering a collector channel, the pathchange will quickly become apparent because of the illuminated distaltip of the microcannula.

The positioner 400 may remain stationary relative to the eye 1000 whilethe composite microcannula moves through Schlemm's canal or other partsof the eye. The positioner 400 may hold the composite microcannulastationary relative to the eye, for example while a payload is beingdelivered through the composite microcannula to a target region in theeye. Although the examples of a trocar in FIGS. 19-22 do not includefinger grips, the examples apply also to a trocar with a finger grip. Afinger grip may be used to immobilize the positioner, for example byholding the finger grip to a patient's skin with adhesive tape or atemporary stitch.

Some embodiments of a trocar are configured to receive two light guides.One of the light guides may be included in a composite microcannula aspreviously described. The second light guide may be in another compositemicrocannula or may be provided independently of a compositemicrocannula. Examples of a trocar adapted for two light guides areshown in FIGS. 23 and 24 . In the example of FIG. 23 , the compositemicrocannula 300 is shown with its distal end 308 extending out from thedistal end 202 of the trocar 200, and with light 614 being emitted fromthe light guide in the composite microcannula. An optional second lightguide 412 is also positioned in the lumen of the trocar 200, with thedistal end 413 of the second light guide 412 remaining inside thetrocar, radiating light 612 from the distal end of the trocar. Assuggested in FIG. 24 , the two light guides may optionally selectivelyilluminate the distal end 202 of the trocar 200 only, the distal end 326of the composite microcannula only, or both, either sequentially orsimultaneously. The emitted light (612, 614) may optionally have awavelength and/or intensity not visible to unaided human vision.

An optional camera 616 may be provided to capture images of the emittedlight (612, 614) passing through eye tissue from the trocar and/ormicrocannula. The positions of the composite microcannula and trocar maybe visible in an image from the camera 616 presented on a computermonitor, smart phone display, and/or instrument display. In somemicrosurgical instrument embodiments 100, the composite microcannula 300and the second light guide 412 may both receive light from the samelight source. The composite microcannula may be advanced until itreaches a target region 1014, for example an area to be cleared of anobstruction or constriction, or an area that will receive a payloaddelivered through the composite microcannula.

FIG. 25 shows an example of a payload 620 carried in the void 303 insidethe flexible hollow tube 302 of a composite microcannula 300. Thepayload may follow the fluid path 324 through the compositemicrocannula. The composite microcannula may therefore be used toprecisely position the payload in a target region of an eye. The payload620 may be a solid object 624, a fluid 622, for example a fluidcomprising a gas and/or a liquid, or both a solid object and a fluid.The fluid may optionally be used to transport a solid object 624, or along solid payload may be pushed in from the proximal end of thecomposite microcannula until the payload extends out the distal end ofthe composite microcannula. The example of a composite microcannula 300in FIG. 25 has a light guide 304 inside the flexible hollow tube. Otherembodiments of a composite microcannula 300 disclosed herein may also beused to deliver a payload 620.

FIGS. 26, 27, and 28 show an example of a trocar entry point markinginstrument 800, also referred to as a marking jig 800. The markinginstrument may be used to form a pattern of tangent lines on the scleraof an eye. The pattern of lines marks at least one, and optionally morethan one, preferred trocar entry point and preferred trocar insertiondirection for guiding a trocar 200 through the sclera into the interiorfluid passage in Schlemm's canal. The marking instrument 800 includes atleast one pair of marking pads 810, 812. Each marking pad 810, 812 ispreferably positioned to form a line tangent to Schlemm's canal when anedge 808 of a sighting aperture through a hub 806 is concentric with thepupil of the eye. A dye applied to a contact surface 814 on each markingpad 810, 812 may be transferred to the sclera 1002 as intersecting linesegments when the contact surfaces touch the surface of the eye.

The two marking pads 810, 812 in each pair are disposed at an angle toone another such that the intersection of the two line segments formedon the eye marks the location of the preferred trocar entry point 606.The intersection point of the two line segments is preferably offset bya predetermined separation distance 826 from the limbus 1008, measuredin a radial direction from the center 1018 of the pupil. The limbus 1008indicates the underlying position of Schlemm's canal 1010 withsufficient precision for the markings made by the two pads 810, 812 toaccurately indicate the insertion position and direction of the distalend of the trocar for entry into Schlemm's canal. The predeterminedseparation distance may be determined from a selected length of eachline segment to be marked on the eye and from the number of separatetrocar entry points 606 to be marked on the eye.

The pairs of pads 810, 812 may be connected to a central hub 806. Ahandle 802 may be attached to the central hub 806. The pads 810, 812 maybe connected directly to the hub, or may alternatively be connected tothe hub by an intervening radial arm 804. The example of a trocar entrypoint marking instrument 800 in FIG. 26 includes a hub 806 with sevenradial arms 804. A first marking pad 810 and a second marking pad 812disposed at an angle to the first marking pad are connected to eachradial arm 804. An alternative embodiment of a marking jig 800 may havea different number of radial arms and marking pads than are shown in thefigures.

FIG. 29 shows an example of trocar entry point markings made on theexterior surface of an eye by the marking instrument 800 of FIGS. 26-28. In the example of FIG. 29 , the iris 1006 is represented as a shadedarea between the edge of the pupil 1016 and the limbus 1008, withSchlemm's canal 1010 close to the limbus. The limbus 1008, Schlemm'scanal 1010, and edge of the pupil 1016 are represented in FIG. 29 bydashed lines to distinguish these lines from markings made by theinstrument 800. The sclera 1002 is represented in FIG. 29 by areasoutside the perimeter of the limbus 1008.

Each pair of marking pads 810, 812 prints a corresponding pair of linesegments 818, 820 tangent to Schlemm's canal 1010. Each pair of linesegments 818, 820 meets at an intersection point 822 corresponding to atrocar entry point 606 on the sclera. More than one entry point 606 maybe marked to provide a choice of trocar insertion points for reaching atarget area in an eye. Each intersection point 822 is offset in a radialdirection from the limbus 1008 by the predetermined separation distance826. A dot or other marking may be placed at each intersection point 822to enhance visibility of the positions of the trocar entry points 606.

After the trocar entry point marking instrument 800 transfers thepattern of intersection line segments from the example of FIG. 29 to thesurface of the eye, one of the intersection points 822 may be selectedfor insertion of the trocar through the sclera. The distal end 210 ofthe trocar 200 is preferably placed in direct contact with theintersection point 822 on the sclera. The shaft 206 of the trocar ispreferably made parallel to one of the line segments 818, 820 and thetrocar advanced parallel to the line segment in the direction from theintersection point 822 to the limbus 1008 until the illuminated distalend 220 of the trocar is observed to enter Schlemm's canal 1010. Afterthe trocar enters Schlemm's canal, the composite microcannula 300 may beextended from the end of the trocar as described for the examples ofFIGS. 21 and 22 .

FIG. 30 shows an example of some steps included with a methodembodiment. A method in accord with an embodiment 700 may include anyone or more of the following steps, in any combination:

at step 702, placing a distal end of a composite microcannula within alumen of a trocar; and

at step 704, selecting a structure in an eye for receiving the trocar.Schlemm's canal, a collector channel, and a blood vessel are examples ofstructures which may be selected, but it will be appreciated thatembodiments of the microsurgical instrument 100 may be used to introducea composite microcannula into other chambers, vessels, or channels in aneye or another organ.

The example of a method embodiment may further include:

at step 706, selecting a trocar entry point on an eye;

at optional step 708, marking a trocar entry point with a marking jig,for example the trocar entry point marking instrument 800 in the exampleof FIG. 26 ;

at step 710, illuminating the distal end of the composite microcannula,thereby illuminating the distal end of the trocar;

at step 712, positioning the trocar at the selected trocar entry point;

at step 714, advancing the trocar from the selected trocar entry pointuntil the illuminated distal end of the trocar is observed to enter theselected structure in the eye; and

at step 716, extending the composite microcannula from the distal end ofthe trocar toward a target region in the eye, thereby transitioning fromilluminating the distal end of the trocar to illuminating tissue outsidethe trocar. Examples of a target region include, but are not limited to,a chamber, vessel, channel or canal blocked by obstructing material, anda collapsed or constricted space to be enlarged or re-opened.

The example method embodiment may optionally include any one or more of:

holding the distal end of the composite microcannula stationary relativeto the trocar;

selecting Schlemm's canal as the structure to be entered by theilluminated distal end of the trocar;

advancing the trocar from the selected trocar entry point along a linetangent to Schlemm's canal;

marking the trocar entry point at the intersection of two lines, each ofthe two lines tangent to Schlemm's canal;

positioning the two tangent lines to intersect a preferred distance fromthe limbus of an eye;

centering a marking instrument over the pupil of an eye and pressing themarking instrument against the eye to mark the two tangent lines ontothe surface of the eye;

marking more than one trocar entry point each time the markinginstrument is pressed against the eye;

illuminating the distal end of the trocar with another light guide;

inserting a payload into the composite microcannula and delivering thepayload to the target region;

illuminating the distal end of the trocar with electromagnetic radiationhaving a wavelength not visible to unaided human vision and observingthe distal end of the trocar with a camera sensitive to theelectromagnetic radiation;

withdrawing the composite microcannula through the trocar while keepingthe trocar at the trocar entry point;

inserting a payload into the composite microcannula;

moving the payload through the composite microcannula to the targetregion;

retracting the composite microcannula with the payload remaining in thetarget region; and

keeping the trocar stationary relative to the eye after the distal endof the trocar enters the selected structure in the eye.

FIGS. 34, 35, and 36 show another example of a microsurgical instrumenthaving a positioner configured for extending and retracting a compositemicrocannula through the lumen of a trocar. The positioner 400 isconfigured for attachment of a trocar 200 to the distal end 418 of ahandpiece 420. The composite microcannula 300 passes through the lumenof the trocar 300 and through the handpiece 420, where the microcannulais coupled to an insert 488 slidably engaged with the handpiece 420. Aswill be explained in more detail below, sliding an actuator 424 in aslot 428 on the handpiece 420 by a selected distance 484 causes acorresponding displacement of the composite microcannula with respect tothe end of the trocar's rigid hollow shaft 206 by a distance 486 equalto twice the displacement distance 484 of the actuator. The trocar 200and the composite microcannula 300 may be provided separately from thepositioner 400 and may be removable for replacement should either thetrocar or microcannula become damaged, contaminated, or otherwiseunusable for a particular procedure.

Some internal features of the example positioner 400 of FIG. 34 areshown in two cross-sectional views in FIG. 36 . Section H-H in FIG. 36shows the actuator 424 retracted toward the proximal end 416 of thehandpiece 420. Section J-J shows the actuator advanced toward the distalend 418 of the handpiece 420. The two views of the handpiece 420 arereferenced to one another in FIG. 36 so that the positions of internalcomponents may be accurately compared between the cross-sections.

The insert 488 is slidably engaged with the interior surface of a voidformed inside the handpiece 420. The actuator 424 travels along one ormore guide ridges 430. A U-shaped hollow tube 492 attached to theactuator 424 moves with the actuator. An insert displacement wire 490passes slidably through the lumen of the U-shaped hollow tube 492. Oneend of the insert displacement wire 490 is affixed to the insert 488.The opposite end of the insert displacement wire 490 is affixed to ananchor post 494 strongly attached to, or alternately formed as anintegral part of, the handpiece 420. The insert displacement wire 490 ispreferably flexible enough to slide easily around the bend in theU-shaped hollow tube 492, yet stiff enough to push the insert 488 in adistal direction (i.e., away from the trocar 200) when the actuator isdisplaced in a distal direction.

With one end of the insert displacement wire 490 fixed to the handpieceat the anchor post 494 and the other end of the wire fixed to the insert488, a sliding displacement of the actuator 424 along the handpiece by adistance “d” 484 causes the U-shaped hollow tube 492 to be displaced bythe same distance “d” and the insert 488 to be displaced by twice asmuch (2×d), represented in the figures by a relative displacement 486 ofthe insert between cross sections H-H and K-K. The compositemicrocannula 300 is coupled to the insert 488 sufficiently strongly tokeep the composite microcannula stationary relative to the insert whenthe actuator is moved relative to the handpiece. Because the insertmoves twice the displacement distance 484 of the actuator, the compositemicrocannula also moves twice the displacement distance 484 of theactuator. Moving the actuator proximally by a distance “d” 484 extendsthe composite microcannula from the trocar by a distance “2×d” 486.Moving the actuator distally by a distance “d” retracts the compositemicrocannula by a distance “2×d”.

The composite microcannula 300 may pass through a hollow sleeve having afixed segment 436 attached to, or alternately formed as an integral partof, the rigid hollow shaft 206 of the trocar 200. A movable segment 434of the hollow sleeve is slidably engaged with the fixed segment 436 atone end and attached to the insert 488 at the other end. The hollowsleeve limits transverse deflection of the composite microcannula as theactuator is advanced and retracted, forcing the composite microcannulato extend and retract without kinking or significant bending inside thehandpiece.

As suggested in the example of FIG. 36 , the composite microcannula 300may extend outward from the proximal end 416 of the positioner 400 andinsert 488. The proximally-extending portion of the compositemicrocannula may be configured to receive solid and/or liquid payloads,surgical instruments, and one or more optical fibers as previouslydescribed.

Unless expressly stated otherwise herein, ordinary terms have theircorresponding ordinary meanings within the respective contexts of theirpresentations, and ordinary terms of art have their correspondingregular meanings.

What is claimed is:
 1. An apparatus, comprising: a trocar comprising arigid shaft having a proximal end and a distal end, said rigid shaftformed with a lumen extending from said proximal end through said distalend, said distal end shaped to puncture a sclera of an eye; a compositemicrocannula positioned in said lumen, comprising: a flexible hollowtube having an outer diameter less than an inner diameter of said lumen;and a layer of material within said flexible hollow tube, said layer ofmaterial surrounding a lumen of said flexible hollow tube, said layer ofmaterial formed as a light guide having a different index of refractionfrom an index of refraction of said flexible hollow tube fortransmitting light coupled into a proximal end of said compositemicrocannula to a distal end of said composite microcannula duringextension of said composite microcannula beyond said distal end of saidrigid shaft, wherein said composite microcannula is controllablyextendable beyond said distal end of said trocar further into the eyeafter puncture of the sclera has been achieved; a handpiece; an actuatorslidably coupled to said handpiece; an insert slidably coupled to saidhandpiece; a hollow tube attached to said actuator; and a wire passingthrough said hollow tube, a first end of said wire attached to saidhandpiece and a second end of said wire attached to said insert.
 2. Theapparatus of claim 1, further comprising said flexible hollow tubeformed with a void space extending from a proximal end of said compositemicrocannula to a distal end of said composite microcannula, and saidlayer of material disposed concentrically around said void space insidesaid flexible hollow tube.
 3. The apparatus of claim 1, furthercomprising said trocar attached to said handpiece.
 4. The apparatus ofclaim 3, further comprising said composite microcannula coupled to saidinsert.
 5. The apparatus of claim 4, further comprising a movable sleeveslidably engaged with said rigid shaft, said movable sleeve attached tosaid insert, and said composite microcannula passing through saidmovable sleeve.
 6. The apparatus of claim 1, wherein said hollow tube isgenerally U-shaped.
 7. The apparatus of claim 1, wherein said compositemicrocannula has an outer diameter and a flexural rigidity configured toenable said composite microcannula to follow a Schlemm canal.
 8. Anapparatus, comprising: a trocar comprising a rigid shaft having aproximal end and a distal end, said rigid shaft formed with a lumenextending from said proximal end through said distal end, said distalend shaped to puncture a sclera of an eye; a composite microcannulapositioned in said lumen, comprising: a flexible hollow tube having anouter diameter less than an inner diameter of said lumen; and a layer ofmaterial within said flexible hollow tube, said layer of material havinga different index of refraction from an index of refraction of saidflexible hollow tube, wherein said composite microcannula iscontrollably extendable beyond said distal end of said trocar furtherinto the eye after puncture of the sclera has been achieved; ahandpiece; an actuator slidably coupled to said handpiece; an insertslidably coupled to said handpiece; a hollow tube attached to saidactuator; and a wire passing through said hollow tube, a first end ofsaid wire attached to said handpiece and a second end of said wireattached to said insert.
 9. The apparatus of claim 8, further comprisingsaid trocar attached to said handpiece.
 10. The apparatus of claim 8,further comprising said composite microcannula coupled to said insert.11. The apparatus of claim 8, further comprising a movable sleeveslidably engaged with said rigid shaft, said movable sleeve attached tosaid insert, and said composite microcannula passing through saidmovable sleeve.
 12. The apparatus of claim 8, wherein said hollow tubeis generally U-shaped.